Document Outline

• Table of Contents
• Introduction
• Plain language
• How to use this brochure
• Section 1. Health Maintenance Organizations
• Section 2. How we change for 2000
• Section 3. How to get benefits
• Section 4. What to do if we deny your claim or request for service
• Section 5. Benefits
• Section 6. General exclusions Things we dont cover
• Section 7. Limitations Rules that affect your benefits
• Section 8. FEHB FACTS
• Inspector General Advisory: Stop Health Care Fraud!
• Summary of Benefits for Kaiser Foundation Health Plan of Colorado 2000
• Premiums

Pages 1--36 from Kaiser Foundation

Kaiser Foundation
Health Plan of Colorado 2000

A Health Maintenance Organization

Serving
Metropolitan Denver Colorado Area
Colorado Springs Colorado Area

Enrollment in this Plan is limited see page 5 for requirements
Enrollment code
651 Self Only
652 Self and Family

This plan has commendable accreditation
from the NCQA See the FEHB Guide
for more information on NCQA

Visit the OPM website at http www opm gov insure and
our National Web site at http www kaiserpermanente org

Authorized for distribution by the
United States Office of
Personnel Management
retirement and insurance service

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Kaiser Foundation Health Plan of Colorado 2000
Table of Contents
Page
Introduction 2
Plain language 2
How to use this brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 4
Section 3 How to get benefits 5
Section 4 What to do if we deny your claim or request for service 8
Section 5 Benefits 10
Section 6 General exclusions Things we don't cover 24
Section 7 Limitations Rules that affect your benefits 25
Section 8 FEHB FACTS 26
Inspector General Advisory Stop Healthcare Fraud 30
Summary of benefits 31
Premiums Back cover

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Kaiser Foundation Health Plan of Colorado 2000
Introduction
Kaiser Foundation Health Plan of Colorado
2500 South Havana Street
Aurora Colorado 80014

This brochure describes the benefits you can receive from Kaiser Foundation Health Plan of Colorado under its contract CS 1268
with the Office of Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This
brochure is the official statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits
described in this brochure If you are enrolled for Self and Family coverage each eligible family member is also entitled to these
benefits

OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on
page 4 Premiums are listed at the end of this brochure

Plain language
The President and Vice President are making the Government's communication more responsive accessible and understandable to
the public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have
worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary
technical terms you and other personal pronouns active voice and short sentences

We refer to Kaiser Foundation Health Plan of Colorado as this Plan throughout this brochure even though in other legal documents
you will see a plan referred to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable

We have not rewritten the Benefits section of this brochure You will find new benefits language next year

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Kaiser Foundation Health Plan of Colorado 2000
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits
with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier

1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and
how they work

2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision
not to pay for your claim or to deny your request for a service

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information
about non FEHB benefits

6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB FACTS Read this for information about the Federal Employees Health Benefits FEHB Program

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Kaiser Foundation Health Plan of Colorado 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and
other providers that contract with us These providers coordinate your health care services The care you receive includes preventive
care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury

When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copayments
and coinsurance listed in this brochure When you receive emergency services or follow up or continuing care under this
Plan's travel benefit you may have to submit claim forms

You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change
plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available
and or remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment

Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary changes care office visits

This year you have a right to more information about this Plan care management our networks
facilities and providers

If you have a chronic or disabling condition and your provider leaves the Plan at our request you
may continue to see your specialist for up to 90 days If your provider leaves the Plan and you
are in the second or third trimester of pregnancy you may be able to continue seeing your
OB GYN until the end of your postpartum care You have similar rights if this Plan leaves the
FEHB program See Section 3 How to get benefits for more information

You may review and obtain copies of your medical records on request If you want copies of
your medical records ask your health care provider for them You may ask that a physician
amend a record that is not accurate not relevant or incomplete If the physician does not amend
your record you may add a brief statement to it If they do not provide you with your records
call us and we will assist you

If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years
This screening is for colorectal cancer

Changes to this Your share of the non postal premium will increase by 1 for Self Only or 1 for Self and Plan Family

The copay for outpatient surgery visits will increase from 10 to 50 See page 10
The copay for diagnosis and treatment of infertility will increase to 50 of charges See page
11

The maximum number of covered outpatient short term rehabilitative therapy visits will
decrease from 30 visits to 20 visits See page 11

Coverage for drugs related to infertility treatment has been eliminated See page 19
The copays for child and adult prophylaxis fluoride treatments and sealant services will be
reduced See page 20

Pulmonary rehabilitation is now covered with a 50 copay See page 12

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Kaiser Foundation Health Plan of Colorado 2000
Section 3 How to get benefits
What is this Plan's To enroll in this Plan you must live in our service area This is where our providers practice service area Our service area is
Denver These zip codes in Adams Arapahoe Boulder Clear Creek Denver Douglas Elbert
Gilpin Jefferson Larimer Park and Weld counties

80001 7 80010 22 80024 28 80030 31 80033 34 80036 38 80040 42 80044 47 80102
80104 80107 80110 12 80116 17 80120 28 80131 80134 35 80137 38 80150 51 80154 55
80160 63 80201 12 80214 39 80241 80243 44 80246 80248 52 80254 56 80259 66 8027071
80273 75 80279 81 80290 95 80299 80301 4 80306 10 80314 80321 23 80328 29
80401 3 80421 22 80425 80427 80433 80437 80439 80452 55 80457 80465 66 80470 71
80474 80481 80501 4 80510 80513 14 80516 80520 80530 80533 34 80537 40 80542 44
80601 80614 80621 80623 80640 80642 43 80651

Colorado Springs These zip codes in Douglas El Paso Fremont Park and Teller counties
80106 80118 80132 33 80808 09 80813 14 80816 17 80819 20 80827 80829 80831 33
80840 41 80860 80863 64 80866 80900 01 80903 22 80925 26 80928 37 80940 47 8094950
80960 80962 80970 80977 80995 80997 81007 08 81212 81240

Ordinarily you must receive your care from physicians hospitals and other providers who contract
with us However we are part of the Kaiser Permanente Medical Care Program and if you
are visiting another Kaiser Permanente service area you can receive virtually all of the benefits
of this Plan at any other Kaiser Permanente facility We also pay for certain follow up services
or continuing care services while you are traveling outside the service area as described on page
14 and for emergency care obtained from any non Plan provider as described on page 15 We
will not pay for any other health care services

If you or a covered family member move outside of our service area you can enroll in another
plan If your dependents permanently reside outside of the area you should consider enrolling in
another plan If you or a family member move you do not have to wait until Open Season to
change plans Contact your employing or retirement office

How much do I You must share the cost of some services This is called either a copayment a set dollar amount pay for services or coinsurance a set percentage of charges Please remember you must pay this amount when
you receive services If you do not pay at the time you receive your service you will be billed
for the service We also will bill you an additional 10 This charge will be added to each service
for which you did not pay

After you pay 2,000 in copayments or coinsurance for one family member or 4,500 for two
or more family members you do not have to make any further payments for certain services for
the rest of the year This is called a catastrophic limit However copayments or coinsurance for
your prescription drugs dental services cosmetic services chiropractic services extended care
services durable medical equipment external prostheses and braces the 25 charges paid for
follow up or continuing care and all mental conditions services except the first 20 outpatient visits
do not count toward these limits and you must continue to pay for these services as described
in this brochure

Be sure to keep accurate records of your copayments and coinsurance since you are responsible
for informing us when you reach the limits

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Kaiser Foundation Health Plan of Colorado 2000
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a submit claims provider who doesn't contract with us or you receive follow up or continuing care under the
travel benefit If you file a claim please send us all of the documents we need to respond to your
claim as soon as possible You must submit claims by December 31 of the year after the year you
received the service Either OPM or we can extend this deadline if you show that circumstances
beyond your control prevented you from filing on time

Who provides Kaiser Permanente offers comprehensive health care at 16 Plan facilities conveniently located my health care throughout the Denver metropolitan area through participating providers in the Colorado Springs
metropolitan area and through referral specialists hospitals and other providers in the community
Health Plan contracts with the Colorado Permanente Medical Group an independent multispecialty
group of physicians Plan physicians to provide or arrange all necessary physician
care for Plan members Medical care is provided through physicians nurse practitioners physician
assistants and other skilled medical personnel working as medical teams at Kaiser
Permanente facilities Specialists in most major specialties are available as part of the medical
teams for consultation and treatment Other necessary medical services such as physical therapy
laboratory and X ray services are available at Kaiser Permanente facilities Plan physicians can
also arrange any necessary specialty care Hospital care is provided through the Plan at several
local community hospitals Dental services are provided by DELTA Exclusive Provider Option
PanelDentists

You must receive your health care services at Plan facilities except if you have an emergency If
you are visiting another Kaiser Permanente service area you may receive health care services
from those Kaiser Permanente facilities This Plan also offers a benefit that will allow you to
receive follow up or continuing care while you travel anywhere

Your primary care physician PCP either a family practitioner pediatrician or internist will
coordinate most aspects of your health care including arranging for you to receive services from
a specialist This Plan will cover specialists services only when your primary care physician
refers you However a woman may see her gynecologist without having to obtain a referral You
may also receive mental health services without a referral

Choose your primary care physician from this Plan's provider directory It lists Plan facilities and
services available at each facility generally family practice pediatrics gynecology and internal
medicine with their locations and phone numbers and notes whether or not the physician is
accepting new patients Directories are updated on a regular basis and are available at the time of
enrollment or upon request by calling the Customer Service Center at 303 338 3800 for Denver
members or by calling Customer Service at 888 681 7878 for Colorado Springs members If you
want to receive care from a specific physician who is listed in the directory call the physician to
verify that he or she still participates with the Plan and is accepting new patients

Notify the Plan of the primary care physician you choose If you need help choosing a primary
care physician call the Plan You may change your primary care physician by notifying the Plan
at any time You are free to see other Plan physicians if your primary care physician is not available
and to receive care at other Kaiser facilities

What do I do if my Call us We will help you select a new one primary care physician
leaves the Plan
What do I do if I need Your primary care physician or specialist will make the necessary arrangements and continue to to go into the hospital supervise your care

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Kaiser Foundation Health Plan of Colorado 2000
What do I do if First call our Customer Service Center at 303 338 3800 for Denver members or 888 681 7878 I'm in the hospital for Colorado Springs members If you are new to the FEHB Program we will arrange for you to
when I join this Plan receive care If you are currently in the FEHB Program and are switching to us your former plan will pay for the hospital stay until

You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first

These provisions only apply to the person who is hospitalized
How do I get Your primary care physician will determine if you need care from a specialist He or she will specialty care obtain necessary authorizations from the Plan The referral will describe the services you will
receive You should return to your primary care physician after your consultation with the specialist
If your specialist recommends additional visits or services your primary care physician
will review the recommendation and authorize the visits or services as appropriate You should
not go to a specialist unless your primary care physician and your Plan has authorized the referral

If you need to see a specialist frequently because of a chronic complex or serious medical condition
your primary care physician will develop a treatment plan that allows you to see your specialist
for a specified number of visits You will not need to obtain additional referrals Your primary
care physician will obtain Plan authorization for these visits

What do I do if Your primary care physician will decide what treatment you need If your primary care I am seeing a specialist physician decides to refer you to a specialist ask if you can see your current specialist If your
when I enroll current specialist does not participate with us you must receive treatment from a specialist who does Generally we will not pay for you to see a specialist who does not participate with our
Plan
What do I do if Call your primary care physician who will arrange for you to see another specialist You may my specialist receive services from your current specialist until we can make arrangements for you to see
leaves the Plan someone else
But what if I have Please contact us if you believe your condition is chronic or disabling You may be able to a serious illness and continue seeing your physician for up to 90 days after we notify you that we are terminating our
my provider leaves the contract with the provider unless the termination is for cause If you are in the second or third Plan or this Plan trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum
leaves the Program care
You may also be able to continue seeing your physician if this Plan drops out of the FEHB
Program and you enroll in a new FEHB plan Contact the new plan and explain that you have a
serious or chronic condition or are in your second or third trimester Your new plan will pay for
or provide your care for up to 90 days after you receive notice that your prior plan is leaving the
FEHB Program If you are in your second or third trimester your new plan will pay for the
OB GYN care you receive from your current physician until the end of your postpartum care

How do you authorize Your physician must get our approval before sending you to a hospital referring you to a medical services specialist or recommending follow up care Before giving approval we consider if the service
is medically necessary to prevent diagnose or treat an illness or condition We follow generally
accepted medical practice in providing services to you

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Kaiser Foundation Health Plan of Colorado 2000
How do you decide if When the service or supply including a drug 1 has not been approved by the FDA or 2 it is a service is experimental the subject of a new drug or new device application on file with the FDA or 3 is part of a
or investigational Phase I or Phase II clinical trial as the experimental or research arm of a Phase III clinical trial or is intended to evaluate the safety toxicity or efficacy of the service or 4 is available as the
result of a written protocol that evaluates the service's safety toxicity or efficacy or 5 is subject
to the approval or review of an Institutional Review Board or 6 requires an informed consent
that describes the service as experimental or investigational then this Plan considers that
service supply or drug to be experimental and not covered by the Plan This Plan and its
Medical Group carefully evaluate whether a particular therapy is safe and effective or offers a
degree of promise with respect to improving health outcomes The primary source of evidence
about health outcomes of any intervention is peer reviewed medical literature

Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that
you were unable to make a timely request due to reasons beyond your control

We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information

If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30
days after we receive the additional information If we do not receive the requested information within 60 days we will make our
decision based on the information we already have

When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM to review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim
or request for service
What if I have a Call us at 303 338 3800 Denver Boulder area or 888 681 7878 Colorado Springs area and we serious or life threatening will expedite our review
condition and you haven't responded to my request
for service
What if you have denied If we expedite your review due to a serious medical condition and deny your claim we will my request for care and inform OPM so that they can give your claim expedited treatment too Alternatively you can
my condition is serious call OPM's health benefits Contract Division 3 at 202 606 0755 between 8 00 a m and 5 00 p m or life threatening Serious or life threatening conditions are ones that may cause permanent loss of bodily functions
or death if they are not treated as soon as possible
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our time limits initial denial or refusal of service You may also ask OPM to review your claim if

1 We did not answer your request within 30 days In this case OPM must receive your
request within 120 days of the date you asked us to reconsider your claim

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Kaiser Foundation Health Plan of Colorado 2000
2 You provided us with additional information we asked for and we did not answer within
30 days In this case OPM must receive your request within 120 days of the date we
asked you for additional information

What do I send to OPM Your request must be complete or OPM will return it to you You must send the following information

1 A statement about why you believe our decision is wrong based on specific benefit provisions
in this brochure

2 Copies of documents that support your claim such as physicians letters operative
reports bills medical records and explanation of benefits EOB forms

3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call

If you want OPM to review different claims you must clearly identify which documents
apply to which claim

Who can make the request Those who have a legal right to file a disputed claim with OPM are
1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the
enrolled person's representative They must send a copy of the person's specific written
consent with the review request

Where should I mail Send your request for review to Office of Personnel Management Office of Insurance Programs my disputed claim to Contracts Division 3 P O Box 436 Washington D C 20044
What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our the Plan's denial decision your only recourse is to sue
If you decide to sue you must file the suit against OPM in Federal court by December 31 of the
third year after the year in which you received the disputed services or supplies

What laws apply if Federal law governs your lawsuit benefits and payment of benefits The Federal court will base I file a lawsuit its review on the record that was before OPM when OPM made its decision on your claim You
may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure
described above

Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you the Privacy Act and us to determine if our denial of your claim is correct The information OPM collects during
the review process becomes a permanent part of your disputed claims file and is subject to the
provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this information
to support the disputed claim decision If you file a lawsuit this information will become
part of the court record

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Kaiser Foundation Health Plan of Colorado 2000
Section 5 BENEFITS

Medical and Surgical Benefits
What is Covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan physicians and other Plan providers This includes all necessary office and outpatient surgery
visits You pay 10 for each office visit for the following services and 50 for each outpatient
surgery visit

Preventive care including well baby care and periodic checkups
Mammograms are covered as follows for women age 35 through 39 one mammogram during
the first five years for women age 40 through 49 one mammogram every one or two years for
women age 50 through 64 one mammogram every year and for women age 65 and above one
mammogram every two years at no charge In addition to routine screening medically necessary
mammograms to diagnose or treat your illness

Routine immunizations and boosters at no charge
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays at no charge
Complete obstetrical maternity care for all covered females including prenatal delivery and
postnatal care by a Plan physician The mother at her option may remain in the hospital up to
48 hours after a regular delivery and 96 hours after a cesarean delivery Inpatient stays will be
extended if medically necessary If enrollment in the Plan is terminated during pregnancy benefits
will not be provided after coverage under the Plan has ended Ordinary nursery care of the
newborn child during the covered portion of the mother's confinement for maternity will be
covered under either a Self Only or Self and Family enrollment other care of an infant who
requires definitive treatment will be covered under a Self and Family enrollment

Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including test and treatment materials such as allergy serum
Blood and blood products at no charge
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung kidney simultaneous pancreas kidney liver and lung single and double
transplants allogenetic donor bone marrow transplants autologous bone marrow transplants
autologous stem cell and peripheral stem cell support for the following conditions
acute lymphocytic or non lymphocytic leukemia advanced Hodgkins lymphoma advanced nonHodgkins
lymphoma advanced neuroblastoma breast cancer multiple myeloma epithelial
ovarian cancer and testicular mediastinal retroperitoneal and ovarian germ cell tumors
Transplants are covered when approved by the Medical Group Related medical and hospital
expenses of the donor are covered

Women who undergo mastectomies may at their option have this procedure performed on an
inpatient basis and remain in the hospital up to 48 hours after the procedure

Dialysis office visit charges will be waived if you enroll in Medicare Part B and assign your
Medicare benefits to the Plan

Chemotherapy radiation and respiratory therapy

10 CARE CARE MUST MUST BE BE RECEIVED RECEIVED FROM FROM OR OR ARRANGED ARRANGED BY BY PLAN PLAN PHYSICIANS PHYSICIANS 12
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Kaiser Foundation Health Plan of Colorado 2000
Cardiac rehabilitation covers a Multifit Intervention Program that provides exercise stress testing
exercise prescriptions home self monitored exercise and case management by registered
nurses and 4 educational sessions in Cardiac College to learn about diet exercise lipids
smoking cessation and on site monitored programs

Surgical treatment of morbid obesity
For homebound members within the service area home health services of physicians nurses
and health aides and physical speech and occupational therapists when prescribed or authorized
by your Plan physician who will periodically review the program for continuing appropriateness
and need

Visits to receive injections
Medical management of mental health conditions including drug therapy evaluation and maintenance

All necessary medical or surgical care in a hospital or extended care facility from Plan physicians
and other Plan providers You pay nothing

If you do not pay any of the charges required for services at the time you receive the services you will be billed for those charges
You will also be required to pay an administrative charge of 10 for each service for which a bill is sent

Limited Benefits Oral and maxillofacial surgeryis provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical procedures
occurring within or adjacent to the oral cavity or sinuses including but not limited to treatment
of fractures and excision of tumors and cysts All other procedures involving the teeth or
intra oral areas surrounding the teeth are not covered including shortening of the mandible or
maxillae for cosmetic purposes correction of malocclusion and any dental care involved in treatment
of temporomandibular joint TMJ pain dysfunction syndrome except as covered on page
20

Reconstructive surgerywill be provided to correct a condition resulting from a functional defect
or from injury or surgery that has produced a major effect on the member's appearance and if the
condition can reasonably be expected to be corrected by such surgery A patient and their attending
physician may decide whether to have breast reconstruction surgery following a mastectomy
and whether surgery on the other breast is needed to produce a symmetrical appearance

Short term rehabilitative therapy physical speech and occupational is provided on an outpatient
or inpatient basis when you are confined in a non acute care bed for up to two months per
condition if significant improvement can be expected within two months If you have not
received 20 or more outpatient visits within the two month period you may receive up to 20 outpatient
visits per therapy per condition you pay 10 per outpatient session and nothing for an
inpatient session Speech therapy is limited to treatment of certain speech impairments of organic
origin Occupational therapy is limited to services that assist the member to achieve and maintain
self care and improved functioning in other activities of daily living You may receive inpatient
therapy as part of a specialized therapy program in a specialized rehabilitation facility for up to
two months per condition you paynothing

Diagnosis and treatment of infertilityis covered You pay50 of charges Artificial intrauterine
insemination IUI is covered Intravaginal insemination IVI and intracervical insemination
ICI are not covered Cost of donor sperm and donor eggs and services related to their procurement
and storage are not covered Other assisted reproductive technology ART procedures
such as in vitro fertilization gamete and zygote intrafallopian transfer are not covered Infertility
services are not available when either member of the family has been voluntarily surgically sterilized
Drugs related to infertility treatments are not covered

CARE CARE MUST MUST BE BE RECEIVED RECEIVED FROM FROM OR OR ARRANGED ARRANGED BY BY PLAN PLAN PHYSICIANS PHYSICIANS 11 13
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Kaiser Foundation Health Plan of Colorado 2000
Chiropractic services Up to 20 visits per calendar year of self referred chiropractic services
provided by Participating Chiropractors Covered services include evaluation laboratory services
and X rays and treatment of musculoskeletal disorders You pay 15 per visit The following
are not covered non neuroskeletal disorders vocational rehabilitation services thermography
transportation costs including ambulance prescription drugs vitamins minerals nutritional supplements
or other similar type products MRI or other types of diagnostic radiology and durable
medical equipment or supplies for use in the home

External prosthetic and orthotic devices and braces Durable medical equipment DME
Coverage is provided for those FDA approved external prosthetic and orthotic devices and braces
devices which are in general use and are required because of a defect of form or function of a
permanently inoperative or malfunctioning body part e g breast protheses including the surgical
bra for an external prothesis and the necessary replacement protheses and bras as well The following
items are not covered corrective shoes podiatric use devices and arch supports foot
orthotics dental prostheses devices and appliances except for medically necessary orthodontic
and prosthodontic treatment for cleft lip or cleft palate for newborn Members when prescribed by
a Plan physician unless these services are covered under a dental insurance policy spare or
alternate use devices replacement of lost prosthetic and orthotic devices and repairs adjustments
or replacements necessitated by misuse and devices equipment and prosthetics related to treatment
of sexual dysfunction DME is covered when intended to be used repeatedly and in the
home and when prescribed by a Plan physician Covered items include oxygen insulin pumps
for Type 1 diabetes and infant apnea monitors The Plan uses a DME formulary to determine
which DME items will be provided to members Coverage is limited to the standard equipment
that meets the medical needs of the Member Convenience and luxury items and features are not
covered The following items are not covered electric monitors of bodily functions devices to
perform medical testing of bodily fluids excretions or substances devices not medical in nature
such as whirlpools saunas elevators convenience or comfort items disposable supplies replacement
of lost equipment repair adjustments or replacements necessitated by misuse more than
one piece of durable medical equipment serving essentially the same function except for replacements
and spare or alternate use equipment You pay20 of charges for all external prosthetic
and orthotic devices braces and DME Plan will pay 80 of the charges up to 2,000 per calendar
year oxygen and insulin pumps are not subject to the 2,000 limit

Pulmonary rehabilitationis provided at designated facilities The program consists of an initial
evaluation 6 education sessions 12 exercise sessions and a final evaluation to be completed
within a two to three month period You pay 50 for the program

What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance or governmental licensing attending school or
camp or travel
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
External hearing aids
Homemaker services
Long term rehabilitative therapy
Transplants not listed as covered
Any eye surgery solely for the purpose of correcting refractive defects of the eye such as nearsightedness
myopia farsightedness hyperopia and astigmatism

Devices equipment supplies and prosthetics related to the treatment of sexual dysfunction

12 CARE CARE MUST MUST BE BE RECEIVED RECEIVED FROM FROM OR OR ARRANGED ARRANGED BY BY PLAN PLAN PHYSICIANS PHYSICIANS 14
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Kaiser Foundation Health Plan of Colorado 2000
Hospital Extended Care Benefits
What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan physician You paynothing All necessary services are covered

including
Semiprivate room accommodations when a Plan physician determines it is medically necessary
the physician may prescribe private accommodations or private duty nursing care

Specialized care units such as intensive care or cardiac care units
Prescribed drugs and their administration blood and blood products and the administration of
blood biologicals supplies and equipment ordinarily provided or arranged as part of inpatient
services

Extended care The Plan provides a comprehensive range of benefits for up to 100 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically
appropriate as determined by a Plan physician and approved by the Plan You paynothing All
necessary services are covered including

Bed board and general nursing care
Prescribed drugs and their administration biologicals supplies and equipment ordinarily provided
or arranged by the skilled nursing facility

Hospice care Supportive and palliative care for a terminally ill member is covered in the home or Plan approved hospice facility You paynothing Services include inpatient and outpatient care and
family counseling these services are provided under the direction of a Plan physician who certifies
that the patient is in the terminal stages of illness with a life expectancy of approximately six
months or less

Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan physician You pay 25

Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan physician determines there procedures is a need for hospitalization for reasons totally unrelated to the dental procedure the Plan will
cover the hospitalization but not the cost of the professional dental services Conditions for
which hospitalization may be covered include hemophilia and heart disease the need for anesthesia
by itself is not such a condition

Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis detoxification treatment of medical conditions and medical management of withdrawal symptoms acute detoxification
if the Plan physician determines that outpatient management is not medically appropriate
See page 17 for nonmedical substance abuse benefits

What is not covered
Personal comfort items such as telephone and television
Custodial care and care in an intermediate care facility

CARE CARE MUST MUST BE BE RECEIVED RECEIVED FROM FROM OR OR ARRANGED ARRANGED BY BY PLAN PLAN PHYSICIANS PHYSICIANS 13 15
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Kaiser Foundation Health Plan of Colorado 2000
Benefits Available Away From Home
When you are outside the service area of this Plan you may still receive covered health care services There are two types of coverage
provided under your enrollment in this Plan

Services From Other When you are visiting in the service area of another Kaiser Permanente plan you are entitled to Kaiser Permanente Plans receive virtually all the benefits described in this brochure at any Kaiser Permanente medical
office or medical center and from any Kaiser Permanente provider If the Plan you are visiting
has a charge that is different from the charges listed in this brochure you will have to pay the
charges imposed by the Plan you are visiting If the Kaiser Permanente plan in the service area
you are visiting has a benefit that is different from the benefits of this Plan you are not entitled to
receive that benefit Some services covered by this Plan such as artificial reproductive services
and the services of specialized rehabilitation facilities will not be available in other Kaiser
Permanente service areas If a benefit is limited to a specific number of visits or days you are
entitled to receive only the number of visits or days covered by the plan in which you are
enrolled

If you are seeking routine non emergent or non urgent services you should call the Kaiser
Permanente member services or customer services department in that area and request an appointment
You may obtain routine follow up or continuing care from these Plans even when you
have obtained the original services in the service area of this Plan If you require emergency services
as the result of an unexpected or unforeseen illness that requires immediate attention you
should go directly to the nearest Kaiser Permanente facility to receive care

At the time you register for services you will be asked to pay the charges required by the local
plan

If you plan to travel to an area with another Kaiser Permanente Plan and wish to obtain more
information about the benefits available to you from that Kaiser Permanente Plan please call the
Customer Service Department at 303 338 3800 in Denver and Boulder and 888 681 7878 in
Colorado Springs

Benefits Available If you are outside the service area of this Plan by more than 100 miles or outside the service While You Travel area of any other Kaiser Permanente Plan the following health care services will be covered

Follow up care care necessary to complete a course of treatment following receipt of covered
out of plan emergency care or emergency care received from Plan facilities if the care would
otherwise be covered and is performed on an outpatient basis Examples of covered follow up
care include the removal of stitches a catheter or a cast

Continuing care care necessary to continue covered medical services normally obtained at Plan
facilities as long as care for the condition has been received at Plan facilities within the previous
90 days and the services would otherwise be covered Services must be performed on an outpatient
basis Services include scheduled well baby care prenatal visits medication monitoring
blood pressure monitoring and dialysis treatments The following services are not covered hospitalization
infertility treatments childbirth services and transplants Prescription drugs are not
covered However you may have most prescriptions filled by mail through this Plan's
Prescription Drug Benefit

If you have any questions about how to use these benefits call the Travel Benefit Information
Line at 800 390 3509 You may obtain the Travel Benefits for Federal Employees brochure by
calling this number You should pay the provider at the time you receive the service Submit a
claim to the Plan for the services on the Plan's Claim for Follow up Continuing Care Medical
Services Form with necessary supporting documentation Submit itemized bills and your
receipts to the Plan along with an explanation of the services and the identification information

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Kaiser Foundation Health Plan of Colorado 2000
from your ID card as you would an emergency claim Claims should be submitted to the Claims
Department Kaiser Foundation Health Plan of Colorado P O Box 372970 Denver CO 802376970
Denver Boulder area and the Claims Department Kaiser Foundation Health Plan of
Colorado P O Box 378020 Denver CO 80237 8020 Colorado Springs If the services are covered
under this Travel Benefit you will be reimbursed the reasonable charges for the care up to a
maximum of 1200 per calendar year You pay 25 for each follow up or continuing care visit
This amount will be deducted from the payment the Plan makes to you

Emergency Benefits
What is a A medical emergency is the sudden and unexpected onset of a condition or an injury that you medical emergency believe endangers your life or could result in serious injury or disability and requires immediate
medical or surgical care Some problems are emergencies because if not treated promptly they
might become more serious examples include deep cuts and broken bones Others are emergencies
because they are potentially life threatening such as heart attacks strokes poisonings gunshot
wounds or sudden inability to breathe There are many other acute conditions that the Plan
may determine are medical emergencies what they all have in common is the need for quick
action

Emergencies within If you are in an emergency situation call the Kaiser Permanente Emergency Telephone Line in the service area Denver Boulder at 303 861 3434 The Emergency Care Center located at St Joseph Hospital
Outpatient Entrance 18th Avenue and Humbold Street is open 24 hours a day 7 days a week In
Colorado Springs call the Emergency Telephone Line at 719 265 8838 You will be given
instructions on where you should go to get care The Emergency Telephone Line is open 24
hours a day 7 days a week

In an extreme emergency if you are unable to contact the Emergency Care Center or the
Emergency Telephone Line call the local emergency system e g the 911 telephone system or
go to the nearest hospital emergency room Be sure to tell the emergency room personnel that you
are a Kaiser Permanente member so they can notify Kaiser Permanente You or a family member
must notify the Plan within 48 hours It is your responsibility to ensure that the Plan has been
notified

If you need to be hospitalized the Plan must be notified within 48 hours or on the first working
day following your admission unless it was not reasonably possible to notify the Plan within that
time If you are hospitalized in non Plan facilities and Plan physicians believe care can be better
provided in a Plan hospital you will be transferred when medically feasible with any ambulance
charges covered in full

Benefits are available for care from non Plan providers in a medical emergency only if delay in
reaching a Plan facility would result in death disability or significant jeopardy to your condition

Plan pays Reasonable charges for emergency services to the extent the services would have been covered if
received from Plan providers

You pay 50 for emergency services received from Plan and non Plan providers and facilities within the
service area If you are admitted as an inpatient the charge is waived

Emergencies outside You may obtain emergency and urgent care services from Kaiser Permanente medical facilities the service area and providers when you are in the service area of another Kaiser Permanente plan The facilities
will be listed in the local telephone book under Kaiser Permanente
Benefits are available for any medically necessary health service that is immediately required
because of injury or unforeseen illness

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Kaiser Foundation Health Plan of Colorado 2000
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working
day following your admission unless it was not reasonably possible to notify the Plan within that
time If a Plan physician believes care can be better provided in a Plan hospital you will be
transferred when medically feasible with any ambulance charges covered in full

Plan pays Reasonable charges for emergency services to the extent the services would have been covered if
received from Plan providers

You pay 50 for emergency services received outside the service area
What is covered
Emergency care at a physician's office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including physician services
Ambulance service approved by the Plan you pay 25

What is not covered Emergency care provided outside the service area if the need for care could have been foreseen
before leaving the service area
Medical and hospital costs resulting from a normal full term delivery of a baby outside the service
area

Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency non Plan providers care upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim
form You should submit claims forms to the Claims Department Kaiser Foundation Health Plan
of Colorado P O Box 372970 Denver CO 80237 6970 Denver Boulder area and the Claims
Department Kaiser Foundation Health Plan of Colorado P O Box 378020 Denver CO 802378020
Colorado Springs If you are required to pay for the services submit itemized bills and
your receipts to the Plan along with an explanation of the services and the identification information
from your ID card

Payment will be sent to you or the provider if you did not pay the bill unless the claim is
denied If it is denied you will receive notice of the decision including the reasons for the denial
and the provisions of the contract on which denial was based If you disagree with the Plan's
decision you may request reconsideration in accordance with the disputed claims procedure
described on page 8

Mental conditions
What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental illness or disorders

Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Medical management visits including drug evaluation and maintenance
Hospitalization including inpatient professional services
Diagnosis and treatment of eating disorders through a 12 week outpatient psychiatric intervention
program

16 CARE CARE MUST MUST BE BE RECEIVED RECEIVED FROM FROM OR OR ARRANGED ARRANGED BY BY PLAN PLAN PHYSICIANS PHYSICIANS 18
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Kaiser Foundation Health Plan of Colorado 2000
Outpatient care Visits to Plan physicians consultants or other psychiatric personnel each calendar year you pay 5 for each covered individual therapy visit
If you do not pay any of the charges required for services at the time you receive the services
you will be billed for those charges You will also be required to pay an administrative charge of
10 for each service for which a bill is sent

Inpatient care For the first 20 days of hospitalization each calendar yearyou pay nothing for days 21 through 45 you pay 20 of charges for any additional daysyou pay 50 of charges

Day and night care If in the professional judgment of a Plan physician a member would benefit from day care or night care services up to 90 sessions of such prescribed care are provided each calendar year
For the first 40 days of day night careyou pay nothing for days 41 through 90 you pay 20
of charges for any additional daysyou pay 50 of charges However the number of such sessions
is reduced by two for each day of hospitalization for inpatient Mental Conditions services
received during the calendar year Day and night care sessions of no less than four and no more
than 12 hour duration are provided in a hospital based or residential program Such care
includes all services of Plan physicians and mental health professionals In addition the following
services and supplies as prescribed by a Plan physician are covered room and board psychiatric
nursing care group therapy drugs and medical supplies

What is not covered
Care for psychiatric conditions that in the professional judgment of Plan physicians are not
responsive to therapeutic management

Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless
determined by a Plan physician to be necessary and appropriate

Psychological testing that is not medically necessary to determine the appropriate treatment of a
short term psychiatric condition

Substance abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and drug addiction the
same as for any other illness In addition the Plan provides
Outpatient care
Counseling for diagnosis and referral through chemical dependency treatment services You
paynothing

Determination of the need for and referral to a specialized facility You paynothing
All necessary rehabilitative care from Plan providers You pay20 of charges for covered
services For care received from a community program after referral by a Plan physician the
Plan pays up to 1,300 per member in any 12 month period you pay20 of charges for covered
services and all charges over the benefit maximum
Inpatient care

All necessary rehabilitative care from Plan providers The Plan pays up to 7,000 per member
in any 12 month period you pay20 of charges for covered services and all charges over the
benefit maximum

Up to two treatments in a facility which provides a non medical detoxification program paid by
the Pan at a benefit maximum of 500 per treatment in any 12 month period You paythe
charges over the benefit maximum

CARE CARE MUST MUST BE BE RECEIVED RECEIVED FROM FROM OR OR ARRANGED ARRANGED BY BY PLAN PLAN PHYSICIANS PHYSICIANS 17 19
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Kaiser Foundation Health Plan of Colorado 2000
What is not covered
Treatment that is not authorized by a Plan physician
Care in a specialized alcoholism drug abuse or drug addiction treatment center except as
specifically noted above

Substance abuse treatment on court order or as a condition of parole or probation unless determined
by a Plan physician to be necessary and appropriate

Prescription Drug Benefit
What is Covered Prescription drugs prescribed by Plan or referral physicians or a dentist at a Plan pharmacy or at a pharmacy designated by the Plan if you are a Colorado Springs member will be dispensed for
up to a 60 day supply You pay 5 per prescription or refill It may be possible for you to receive
refills by mail at no extra charge Delivery is available at an additional charge in the
Denver Boulder area only Ask for details at a Plan pharmacy

This Plan uses a formulary to determine which prescribed drugs will be provided to members If
the physician specifically prescribes a nonformulary drug because it is medically necessary the
nonformulary drug will be covered If you request the nonformulary drug when your physician
has prescribed a substitution the nonformulary drug is not covered However you may purchase
the nonformulary drug from a Plan pharmacy at prices charged to members for non covered
drugs

The following drugs are drugs provided at the 5 charge unless another charge is specifically
identified

Drugs for which a prescription is required by law
Oral and injectable contraceptives drugs contraceptive devices and intrauterine devices
Implanted time release drugs such as Norplant You pay a one time payment equal to the 5 per
prescription times the expected number of months the medication will be effective not to
exceed 200 There will be no refund of any portion of these copayments if the implanted timerelease
medication is removed before the end of its expected life

Insulin
Glucose test strips provided at 20 of charges
Disposable needles and syringes needed for injecting covered prescribed drugs provided at
20 of charges

Growth Hormone
Niacin
Food supplements and supplies for individuals unable to absorb or digest food for use in the
home Includes enteral and parenteral elemental dietary formulas and amino acid modified
products for treatment of inborn errors of metabolism at a charge of 3 per day

Injections of Lupron Depot in place of surgery for prostrate cancer you pay 20 of charges
Chemotherapy drugs

The Plan provides the following at no charge

Immunosuppressant drugs required after a covered transplant
Intravenous fluids and medications for home use

18 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS 20
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Kaiser Foundation Health Plan of Colorado 2000
Limited Benefits Drugs to treat sexual dysfunction have dispensing limitations You pay50 of charges Contact the Plan for details
What is not covered
Drugs available without a prescription or for which there is a nonprescription equivalent available

Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Drugs related to infertility services
Condoms

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS 19 21
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Kaiser Foundation Health Plan of Colorado 2000
Other Benefits
Dental care
What is covered The following dental services are covered when provided by participating Plan dentists You are limited to two visits per year for any dental prophylaxis cleaning and to one fluoride treatment
per year for children through age 15 You pay 10 for initial examinations and a 5 charge for
cleanings You paya 5 charge for a cleaning for persons age 15 and older You paynothing for
periodic examinations

Calendar Year Benefit Maximum is limited to 1,000 per member
SCHEDULE OF BENEFITS Procedure Patient Procedure Patient
Code Description Copay Code Description Copay
DIAGNOSTIC 2750 Porc High Noble Metal Crown 365.00 0110 Initial Exam 10.00 2751 Porc Predom Base Metal Crown 312.00
0120 Periodic Exam No Charge 2752 Porc Noble Metal Crown 348.00
0130 Emergency Exam 18.00 2790 Full High Noble Metal Crown 358.00
0210 Full Mouth X Rays 35.00 2791 Full Predom Base Metal Crown 298.00
0220 1 Intraoral Xray 6.00 2792 Full Noble Metal Crown 340.00
0230 Addtnl Intraoral Xray 4.00 2810 3 4 Metallic Crown 350.00
0240 Occlusal Xray 10.00 2920 Recement Crown 26.00
0270 Bitewing 5.00 2930 Prefab Stainless Steel Crown Primary 76.00
0272 2 Bitewings 11.00 2940 Sedative Filling 26.00
0273 3 Bitewings 11.00 2950 Crown Buildup Pin Retained 75.00
0274 4 Bitewings 15.00 2951 Pin Retention Excl Of Restoration 16.00
0330 Panoramic Film 28.00 2952 Cast Post Core In Add To Crown 118.00
0340 Cephalometric Film 27.00 2954 Prefab Post Core No Crown 95.00
0460 Pulp Tests 11.00
0470 Diagnostic Casts 26.00 ENDODONTICS
3220 Therapeutic Pulpotomy 45.00
PREVENTIVE 3310 Root Canal Anterior 195.00 1110 Prophylaxis Adult 5.00 3320 Root Canal Bicuspid 230.00

1120 Prophylaxis Age 0 14 5.00 3330 Root Canal Molar 310.00
1201 Topical Fluoride W Prophy 16.00 3410 Apicoectomy Anterior 190.00
1203 Top Fluoride Child No Prophy 5.00 3421 Apicoectomy Bicuspid 230.00
1204 Top Fluoride Adult No Prophy 5.00 3425 Apicoectomy Molar 235.00
1351 Sealant Per Tooth 9.00
1510 Spacer Fixed Unilateral 85.00 PERIODONTICS
1515 Spacer Fixed Bilateral 130.00 4210 Gingivectomy Per Quad 148.00
4211 Gingivectomy Per Tooth 58.00
RESTORATIVE 4220 Gingival Curettage Per Quad 144.00 2110 Amalgam 1 Surface Primary 29.00 4240 Gingv Flap W Root Pl Per Quad 250.00

2120 Amalgam 2 Surface Primary 36.00 4260 Osseous Surgery Per Quad 640.00
2130 Amalgam 3 Surface Primary 45.00 4341 Perio Root Plan Per Quad 84.00
2140 Amalgam 1 Surface Permanent 34.00 4910 Maintenance Following Therapy 44.00
2150 Amalgam 2 Surface Permanent 44.00
2160 Amalgam 3 Surface Permanent 55.00
2161 Amalgam 4 Surf Plus Permanent 66.00
2330 Anterior Resin 1 Surface 40.00
2331 Anterior Resin 2 Surfaces 52.00
2332 Anterior Resin 3 Surfaces 64.00

20 CARE CARE MUST MUST BE BE RECEIVED RECEIVED FROM FROM OR OR ARRANGED ARRANGED BY BY PLAN PLAN PHYSICIANS PHYSICIANS 22
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Kaiser Foundation Health Plan of Colorado 2000
Procedure Patient Procedure Patient
Code Description Copay Code Description Copay

PROSTHODONTICS 6752 Porcelain Noble Metal Crown 355.00 5110 Complete Upper Denture 423.00
6790 Full High Noble Metal Crown 370.00 5120 Complete Lower Denture 423.00
6791 Full Predom Base Metal Crown 250.00 5130 Comp Immediate Upper Denture 455.00
6792 Full Noble Metal Crown 285.00 5140 Comp Immediate Lower Denture 455.00
6970 Cast Pore Core No Bridge Retainer 100.00 5213 Partial Upper Denture Metal Base 490.00
6972 Prefabricated Post Core No Bridge 80.00 5214 Partial Lower Denture Metal Base 490.00
6973 Retainer Crown Build Up 65.00 5510 Repair Broken Complete Denture 55.00

5520 Replace Missing Broken Teeth 50.00 ORAL SURGERY
5630 Repair Replace Broken Clasp 72.00 7110 Single Tooth Extraction 38.00
5640 Replace Tooth On Denture 50.00 7120 Addtnl Tooth Extraction 34.00
5650 Add Tooth To Partial Denture 60.00 7130 Root Removal Exposed Root 48.00
5660 Add Clasp To Partial Denture 72.00 7210 Surg Ext Erupted Tooth 74.00
5750 Lab Reline Upper Denture 95.00 7220 Rem Imp Tooth Soft Tissue 85.00
5751 Lab Reline Lower Denture 95.00 7230 Rem Imp Tooth Partially Bony 110.00
6210 Cast High Noble Metal Pontic 360.00 7240 Rem Imp Tooth Completely Bony 130.00
6211 Cast Predom Base Metal Pontic 265.00 7250 Surgical Root Recovery 75.00
6212 Cast Noble Metal Pontic 280.00
6240 Porcelain With High Noble Metal Pontic 375.00 ADJUNCTIVE SERVICES
6241 Porcelain Predom Base Metal Pontic 260.00 9110 Palliative Treatment 30.00
6242 Porcelain Noble Metal Pontic 275.00 9310 Consultation 27.00
6750 Porcelain High Noble Metal Crown 380.00
6751 Porcelain Predom Base Metal Crown 265.00

ANY SERVICE NOT LISTED IS THE RESPONSIBILITY OF THE PATIENT AND IS AVAILABLE
ON A USUAL AND CUSTOMARY FEE BASIS

THE ABOVE SERVICES ARE SUBJECT TO THE LIMITATIONS EXCLUSIONS AND
GOVERNING ADMINISTRATIVE POLICIES OF THE PROGRAM

Accidental injury benefit Restorative services and supplies necessary to promptly repair but not replace sound natural teeth are covered The need for these services must result from an accidental injury

Out of area emergencies This benefit pays up to a maximum of 50 for out of area emergency dental expenses
Orthodontic services You pay the usual and customary fee for orthodontic services
What is not covered Cosmetic dental services

Replacement of lost or stolen dentures or bridgework
Dental services not listed as covered

Vision care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye eye refractions to provide a written lens prescription for eyeglasses but not for contact
lenses may be obtained from Plan providers You pay 10 per visit
What is not covered Corrective eyeglass lenses or frames
Examinations for contact lenses or the fitting of contact lenses
Eye exercises

CARE CARE MUST MUST BE BE RECEIVED RECEIVED FROM FROM OR OR ARRANGED ARRANGED BY BY PLAN PLAN PHYSICIANS PHYSICIANS 21 23
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Kaiser Foundation Health Plan of Colorado 2000
Special Benefits for Medicare Eligible Enrollees
If you are enrolled in this Plan through the FEHBP have Medicare Part A coverage and have purchased Part B coverage you also
may enroll in the Kaiser Permanente Senior Advantage program

The Senior Advantage Program Plan provides all Medicare covered Part A and Part B benefits to the Medicare beneficiary as well as
some benefits not covered by Medicare It is an arrangement between Medicare and this Plan in which Medicare pays a specific
amount to this plan for each Medicare beneficiary who enrollees in the Plan

Like your FEHBP enrollment in this Plan you are required to obtain your services from this Plan's physicians and providers except
for emergencies and out of area urgent care The rules regarding enrollment in Kaiser Permanente Senior Advantage are fully
explained in Evidence of Coverage for Senior Advantage Federal Members For a copy of these rules please contact the Customer
Service Center at 303 338 3800

Following your enrollment in Kaiser Permanente Senior Advantage you will be entitled to receive an enhanced benefits package that
combines your FEHBP coverage with your Kaiser Permanente Senior Advantage benefits

If you choose to enroll in Senior Advantage you will be responsible for paying the Part B premium You must make an affirmative
enrollment in Senior Advantage Information regarding enrollment and disenrollment rules may be found in the Evidence of
Coverage for Senior Advantage Federal Members You will also continue to pay the employee share of the FEHBP premium

22 24
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Kaiser Foundation Health Plan of Colorado 2000
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but
are made available to all enrollees and family members of this Plan The cost of the benefits described on this page is
not included in the Disclosure Form FEHB premium and any charges for these services do not count toward any FEHB
deductibles or out of pocket maximums These benefits are not subject to the FEHB disputed claims procedure

As an FEHBP enrollee in this Plan you can receive acupuncture and massage therapy services through Landmark
Heathcare at a 25 discount of the practitioner's standard charges Contact Landmark Healthcare at 800 638 4557 for
more information

BENEFITS BENEFITS ON ON THIS THIS PAGE PAGE ARE ARE NOT NOT PART PART OF OF THE THE FEHB FEHB CONTRACT CONTRACT
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Kaiser Foundation Health Plan of Colorado 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless
your Plan physician determines it is medically necessary to prevent diagnose or treat your illness or condition

We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan doctors or hospitals except for authorized referrals or emergencies and services
received under the travel benefit see Emergency Benefits and Benefits Available Away from
Home

Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother
would be endangered if the fetus were carried to term or when the pregnancy is the result of an
act of rape or incest

Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan

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Kaiser Foundation Health Plan of Colorado 2000
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On occasion
you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain
enrolled with us

If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If
you later want to re enroll in the FEHB Program generally you may do so only at the next Open
Season

If you involuntarily lose coverage or move out of the Medicare Choice service area you may reenroll
in the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and
your benefits will not be reduced We cannot require you to enroll in Medicare

For information on Medicare Choice plans contact your local Social Security Administration
SSA office or request it from SSA at 800 638 6833 For information on the Medicare Choice
plan offered by this Plan see page 22

Other group When anyone has coverage with us and with another group health plan it is called double cover insurance coverage age You must tell us if you or a family member has double coverage You must also send us
documents about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other
plan is secondary it pays benefits next We decide which insurance is primary according to the
National Association of Insurance Commissioners Guidelines

If we pay second we will determine what the reasonable charge for the benefit should be After
the first plan pays we will pay either what is left of the reasonable charge or our regular benefit
whichever is less We will not pay more than the reasonable charge If we are the secondary
payer we may be entitled to receive payment from your primary plan

We will always provide you with the benefits described in this brochure Remember even if you
do not file a claim with your other plan you must still tell us that you have double coverage

Circumstances Under certain extraordinary circumstances we may have to delay your services or be beyond our control unable to provide them In that case we will make all reasonable efforts to provide you with necessary
care
When others are When you receive money to compensate you for medical or hospital care for injuries or illness responsible for injuries that another person caused you must reimburse us for whatever services we paid for We will
cover the cost of treatment that exceeds the amount you received in the settlement If you do not
seek damages you must agree to let us try This is called subrogation If you need more information
contact us for our subrogation procedures

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Kaiser Foundation Health Plan of Colorado 2000
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you
we are the primary payer See your TRICARE Health Benefits Advisor if you have questions
about TRICARE coverage

Workers compensation We do not cover services that
You need because of a workplace related disease or injury that the Office of Workers
Compensation Programs OWCP or a similar Federal or State agency determine they must provide

OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding
that is based on a claim you filed under OWCP or similar laws

Once the OWCP or similar agency has paid its maximum benefits for your treatment we will
provide your benefits

Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency directly Agencies or indirectly pays for

Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the information about right to information about your health plan its networks providers and facilities You can also
your HMO find out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's
website www opm gov insurelists the specific types of information that we must make available
to you

If you want specific information about us call 303 338 3800 in the Denver Boulder service area
and 888 681 7878 in the Colorado Springs service area or write to Kaiser Foundation Health
Plan of Colorado Customer Service Center 2500 South Havana Street Aurora Colorado 800141622
You may visit our website at www kaiserpermanente org

Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information about Employees Health Benefits Plans brochures for other plans and other materials you need to
enrolling in the make an informed decision about FEHB Program

When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military
service or retire
When your enrollment ends and
The next Open Season for enrollment

We don't determine who is eligible for coverage and in most cases cannot change your enrollment
status without information from your employing or retirement office

When are my The benefits in this brochure are effective on January 1 If you are new to this plan your benefits and coverage and premiums begin on the first day of your first pay period that starts on or after
premiums effective January 1 Annuitants premiums begin January 1

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Kaiser Foundation Health Plan of Colorado 2000
What happens When you retire you can usually stay in the FEHB Program Generally you must have been when I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet
this requirement you may be eligible for other forms of coverage such as Temporary
Continuation of Coverage which is described later in this section

What types of coverage Self Only coverage is for you alone Self and Family coverage is for you your spouse and are available for your unmarried dependent children under age 22 including any foster or stepchildren your
my family and me employing or retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support

If you have a Self Only enrollment you may change to a Self and Family enrollment if you
marry give birth or add a child to your family You may change your enrollment 31 days before
to 60 days after you give birth or add the child to your family The benefits and premiums for
your Self and Family enrollment begin on the first day of the pay period in which the child is
born or becomes an eligible family member

Your employing or retirement office will not notify you when a family member is no longer eligible
to receive health benefits nor will we Please tell us immediately when you add or remove
family members from your coverage for any reason including divorce

If you or one of your family members is enrolled in one FEHB plan that person may not be
enrolled in another FEHB plan

Are my medical and We will keep your medical and claims information confidential Only the following will have claims records confidential access to it

OPM this Plan and subcontractors when they administer this contract This plan and appropriate
third parties such as other insurance plans and the Office of Workers Compensation
Programs OWCP when coordinating benefit payments and subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal
actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your
identity or
OPM when reviewing a disputed claim or defending litigation about a claim

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Kaiser Foundation Health Plan of Colorado 2000
Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You
can also use an Employee Express confirmation letter
What if I paid a Your old plan's deductible continues until our coverage begins deductible under
my old plan
Pre existing conditions We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled in this Plan solely because you had the condition before you enrolled

When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when enrollment in Your enrollment ends unless you cancel your enrollment or
this Plan ends You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits spouse coverage under your former spouse's enrollment But you may be eligible for your own FEHB coverage
under the spouse equity law If you are recently divorced or are anticipating a divorce contact
your ex spouse's employing or retirement office to get more information about your coverage
choices

What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For
example you can receive TCC if you are not able to continue your FEHB enrollment after you
retire You may not elect TCC if you are fired from your Federal job due to gross misconduct

Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office

Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums
from the 32nd day after your regular coverage ends even if several months have passed

You pay the total premium and generally a 2 percent administrative charge The government
does not share your costs

You receive another 31 day extension of coverage when your TCC enrollment ends unless you
cancel your TCC or stop paying the premium

You are not eligible for TCC if you can receive regular FEHB Program benefits

How do I enroll in TCC If you leave Federal service your employing office will notify you of your right to enroll under TCC You must enroll within 60 days of leaving or receiving this notice whichever is later

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Kaiser Foundation Health Plan of Colorado 2000
Children You must notify your employing or retirement office within 60 days after your child is
no longer an eligible family member That office will send you information about enrolling in
TCC You must enroll your child within 60 days after they become eligible for TCC or receive
this notice whichever is later

Former spouses You or your former spouse must notify your employing or retirement office
within 60 days of one of these qualifying events

Divorce
Loss of spouse equity coverage within 36 months after the divorce

Your employing or retirement office will then send your former spouse information about
enrolling in TCC Your former spouse must enroll within 60 days after the event which qualifies
them for coverage or receiving the information whichever is later

Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify
your employing or retirement office within the 60 day deadline

How can I convert to You may convert to an individual policy if individual coverage

Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did
not pay your premium you cannot convert

You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law

If you leave Federal service your employing office will notify you if individual coverage is available
You must apply in writing to us within 31 days after you receive this notice However if
you are a family member who is losing coverage the employing or retirement office will not
notify you You must apply in writing to us within 31 days after you are no longer eligible for
coverage

Your benefits and rates will differ from those under the FEHB Program however you will not
have to answer questions about your health and we will not impose a waiting period or limit your
coverage due to pre existing conditions

How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage Certificate of Group that indicates how long you have been enrolled with us You can use this certificate when
Health Plan Coverage getting health insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods
limitations or exclusions for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other
FEHB plans you may request a certificate from them as well

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Kaiser Foundation Health Plan of Colorado 2000
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for services
you did not receive billed you twice for the same service or misrepresented any information do the following

Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 303 338 3800 in Denver or 888 681 7878 in Colorado Springs and explain
the situation

If we do not resolve the issue call or write

THE HEALTH CARE FRAUD HOTLINE
202 418 3300
U S Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington D C 20415

Penalties for Fraud
Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General may investigate
anyone who uses an ID card if they

Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits

Your agency may also take administrative action against you

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Kaiser Foundation Health Plan of Colorado 2000
Summary of Benefits for Kaiser Foundation Health Plan of Colorado 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions
set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or
change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the
cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE
FOLLOW UP AND CONTINUING CARE AND CARE RECEIVED FROM OTHER KAISER PERMANENTE PLANS ARE
COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN PHYSICIANS

Benefits Plan pays provides Page
Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital physician care room and board
general nursing care private room and private nursing care if medically
necessary diagnostic tests drugs and medical supplies use of operating
room intensive care and complete maternity care You paynothing 13

Extended care All necessary services up to 100 days per calendar year
You paynothing 13

Mental conditions Diagnosis and treatment of acute and chronic psychiatric conditions
for the first 20 days at no charge 20 of charges for 21st through 45th
day 50 of charges for each day thereafter 17

Substance Abuse Covered under mental conditions benefits You paynothing
In addition two non medical detoxifications in any 12 month
period up to a benefit maximum of 500 per detoxification in
any 12 month period Also all necessary rehabilitative care
up to a benefit maximum of 7,000 in any 12 month period
You pay20 of charges for covered services 17

Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care preventive care
including well baby care periodic check ups and routine immunizations
laboratory tests and X rays complete maternity care You paya 10
copay per office visit 50 copay per outpatient surgery and nothing
per house call by a physician 10

Home health care All necessary visits by nurses and health aides
You paynothing per visit 11

Mental conditions All authorized mental health outpatient visits are covered
You paya 5 copay 17

Substance abuse Covered under mental conditions benefits as shown and counseling
under chemical dependency treatment services You pay nothing
In addition all necessary rehabilitative care You pay20 of
charges for covered services 17

Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay 50 for each emergency room
visit to Plan or non Plan facilities within the service area and
non Plan facilities outside the service area 15

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Kaiser Foundation Health Plan of Colorado 2000
Prescription drugs Drugs prescribed by a Plan physician and obtained at a Plan pharmacy You paya 5 copay maximum per prescription unit or refill 18

Dental care Preventive dental care you payvarious copays based on procedure rendered For all other dental visits you have
various copays based on the procedure rendered 20

Vision care One refraction annually You paya 10 copay per visit 21

Out of pocket maximum Copayments are required for a few benefits however after your out of pocket expenses reach a maximum of 2,000 per Self Only
or 4,500 per Self and Family enrollment per calendar year
covered benefits will be provided at 100 This copay maximum
does not include prescription drugs or dental services 5

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Notes 35
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Kaiser Foundation Health Plan of Colorado 2000
2000 Rate Information for
Kaiser Foundation Health Plan of Colorado

Non Postalrates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide for that
category or contact the agency that maintains your health benefits enrollment

Postal ratesapply to most career U S Postal Service employees In 2000 two categories of contribution rates referred to as
Category A rates and Category B rates will apply for certain career employees If you are a career postal employee but not a member
of a special postal employment class refer to the categoy definitions in The Guide to Federal Employees Health Benefits Plans
for United States Postal Service Employees RI 70 2 to determine which rate applies to you

Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or associate members
of any postal employee organization Such persons not subject to postal rates must refer to the applicable Guide to Federal
Employees Health Benefits Plans

Non PostalPremium Postal Premuim A Postal Premuim B
Biweekly Monthly Biweekly Biweekly
Type of Gov't Your Gov't Your Gov't Your USPS Your
Enrollment Code Share Share Share Share Share Share Share Share

Self only 651 60.41 20.13 130.88 43.62 71.48 9.06 71.48 9.06
Self and Family 652 154.19 51.40 334.09 111.36 182.46 23.13 182.46 23.13

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